Office surgery, Mora Hospital, outpatient unit, Jan 1999
Office laparoscopy, Office prolapse surgery, Office TVT surgery ....
-- Only local anesthesia + mild sedation! --
Gasless laparoscopy (Camera trocar lifting)
Modern healthcare is expensive, especially surgery performed in a regular operating theatre. General anesthesia involves life-threatening risks and undesirable side effects. Local anesthesia minimizes these drawbacks and can be administered by the surgeon. This promotes simplification.
Many gynecological operations can be performed in an office-based setting under local anesthesia and mild sedation. The women walk to and from the procedure room.
Compared to conscious sedation, mild sedation is safe, avoids occasional side effects such as respiratory depression, headache, hangover, nausea and vomiting, amnesia or unpleasant memories of the surgical experience and eliminates the need for surveillance by professional anesthesia personnel.
Nevertheless, the procedure room should have resuscitation equipment including oxygen and suction, an emergency tray with diazepam, atropine, catastrophic adrenaline and a narcotic antidote. Electrocardiography (ECG) equipment and a pulse oximeter.
Office-based surgery results in reduced morbidity, reduced length of hospital stay, reduced lenght of recovery time, reduced total costs and is associated with high patient compliance and satisfaction.
Examples of operations that can be performed as an office-based procedure are
• Exploratory curettage
• Laser surgery
• Thermal endometrial destruction
• Female sterilization
• Incontinence surgery
• Prolapse surgery
In the year of 1992, an office setting was established in Mora hospital Sweden. At first only uncomplicated operations were performed (abortion, exploratory curettage, hysteroscopy, conization, laser surgery), later more complicated operations (thermal endometrial destruction, gasless laparoscopic sterilization/open access technique, TVT-incontinence surgery) and from 1997 office prolapse surgery.
Personnel included the surgeon, an assistant to arrange the instruments and a midwife to monitor the patient’s blood pressure, pulse rate, respiratory rate, blood oxygen saturation, electrocardiogram, level of sedation and to give medications on request from the surgeon. Only the surgeon was dressed in sterile clothing.
At Mora Hospital in Sweden between 1992 and 1998 and at Nordfjord Hospital in Norway between 2000 and 2005, the use of normal operating theatres was almost halved, despite the increased number of time-consuming laparoscopic procedures used for hysterectomy and adnexal surgery. This is explained by the relocation of many operations from the normal operating theatre to a local anesthetic unit, a low-resource office-based setting. The relocated operations included endometrial curettage, hysteroscopy, abortion, laser surgery (not at Nordfjord Hospital), conization, thermal endometrial destruction (not at Nordfjord Hospital), gasless laparoscopic sterilization, tension-free vaginal tape for incontinence surgery, and prolapse surgery.
At Mora Hospital in 1998, 63% of all operations were performed under local anesthesia and mild sedation, including 50 of 96 prolapse surgeries. Gynecological in- and outpatient services increased by 29%, health care spending decreased by 22%, and waiting times for surgery decreased by 80%.
The use of laparoscopy instead of opensurgery and office-based surgery instead of regular operating roomsurgery dramatically reduced average length of hospital stay and madeit possible to increase the total number of surgeries.At Nordfjord Hospital, the overall satisfaction rate for office-based surgery performed under local anesthesia and mild sedation was 100%, 97%, 98%, 99%, and 98% in 2002–2006, respectively, based on submitted outcome questionnaires. The women walked to and from the operating room for all types of surgery, including prolapse surgery. Office based surgery is safe, convenient for the patient, and inexpensive and leaves the normal operating theatre available for more advanced surgery, such as LH and VH.
Simplicity & Quality